Wisconsin Department of Public Instruction INSTRUCTIONS: Submit original claim to DPI; keep a copy for your files.
CHILD AND ADULT CARE FOOD PROGRAM Submit no later than the 15th of the month following the month covered by
REIMBURSEMENT CLAIM the claim to:
(After School Hours Care Site and WISCONSIN DEPARTMENT OF PUBLIC INSTRUCTION
Emergency Shelter Components) FEDERAL AIDS AND AUDIT SECTION
PL 95-627 P.O. BOX 7841
PI-1489-B (Rev. 06-11) MADISON, WI 53707-7841
Claims submitted more than 60 days after the end of the claiming month
Agreement No. Month Year cannot be paid unless a special exemption is granted by the USDA.
Sponsoring Agency Address Street, City, State, ZIP Telephone Area/No.
I. CHILD AND ADULT CARE FOOD PROGRAM ENROLLMENT DATA
After School Hours Care Site(s) Emergency Shelter(s)
1. Total Enrollment
2. Total Eligible Children
II. PARTICIPATION DATA
After School
Hours Care
Site(s) Emergency Shelter(s)
3. Number of Sites
4. Number of Days of Service
5. Average Daily Attendance
AM PM Additional
Breakfasts Snacks Lunches* Snacks Suppers* Snacks Total
6. Number of Suppers and/or Snacks
Served to Eligible Children 0
(After School Hours Care)
7. Number of Meals Served to Eligible
Children (Emergency Shelters) 0
III. CERTIFICATION
I CERTIFY, to the best of my knowledge, this claim is true and correct in all respects; that records are available to support this claim; that it is in
accordance with the terms of existing agreements(s); and that payment, therefore, has not been received.
Signature of Authorized Representative Title Date Signed

DPI USE Only
Meal Reimbursement Commodity TOTAL
$ $ $
Voucher Number Date of Check
* Cash in lieu of commodities will be paid on these meals. Collection of this information is a requirement of PL 95-627.